Discussion of public health and health care policy, from a public health perspective. The U.S. spends more on medical services than any other country, but we get less for it. Major reasons include lack of universal access, unequal treatment, and underinvestment in public health and social welfare. We will critically examine the economics, politics and sociology of health and illness in the U.S. and the world.

Friday, January 09, 2009

Okay, now where were we?

Sorry for erratic posting, I'm dealing with a family emergency. It may take me off line for a few days, but I'll let you know.

Anyway, Borderline Personality Disorder is terrible nomenclature and I really wish they'd change it. The name comes from a time when they thought BPD was somewhere on the borderline (get it?) between the historic constructs of psychosis and neurosis. (Those terms are still used, but the meaning has evolved somewhat.) The idea is that people with the diagnosis stubbornly interpret reality in ways which differ from the perceptions of others, i.e. there is something close to delusional about them, it just drives you nuts trying to get them to have useful insight into their own behavior.

Specifically, and this is my personal description, it's not by the book, people -- who are mostly female -- with this diagnosis have a powerful aversion to being alone and a pervasive fear of loneliness and abandonment. This causes them to develop extravagant crushes, romantic or otherwise, on people who may not reciprocate the attraction -- or who may exploit it -- and to be highly manipulative, clinging and needy in these relationships, whether the relationships exist largely in their own heads or have some mutuality. Naturally, this excessive neediness and the passive-aggressive manipulativeness that comes with it has the effect of driving its objects away, whereupon the person develops a narrative of victimhood and cruel abandonment, putting all the blame on the formerly beloved object who is now utterly contemptible. Along this path there may be an episode of stalking behavior.

As you can see, the people who are most likely to be attracted to this person include narcissists and sociopaths, so you may have some very ugly situations.

The conventional etiological story about this is quite Freudian sounding, and also intuitively fairly convincing. The idea is that it comes from a failure to internalize objects, specifically the protective and nurturing adults of infancy. Babies eventually get the idea that even though Mommy isn't here right at this moment, she still exists and will come back. We learn to comfort ourselves with the dependable love of people even when they aren't with us. As adults, even the deceased are still a part of us. But if you can't do this, you have a problem.

And indeed, people with the diagnosis have a higher than usual prevalence of lack of nurturing during infancy and childhood, even of abuse. It doesn't have to be there, but it's a pretty good indication if it is.

Now, here's my argument for the essential validity of classifying this as inherently a deficit in a human personality, whether or not you like the term "disease," and why this is not similar to labeling homosexuality as a pathology. It turns out that the only reason homosexuals have historically been unhappy and even suicidal is because they have been despised and persecuted. Take away the stigma, and you take away the problem. We now know, from ample experience, that it is perfectly possible to be happy and functional as a homosexual so long as you are in an environment which is sufficiently accepting and affirming. Take it from me, I live in Jamaica Plain and work in the South End. (I'm not gay, but I'm fabulous anyway.)

But the problem with BPD or whatever you want to call it is not moral stigma. People who behave that way are inherently difficult and burdensome to others. It is very difficult to imagine a human society in which BPD is not dysfunctional and a continual source of grief and pain, for the sufferer and those around her. Human social organization is hugely variable, but it is built out of a finite set of elements that work something like Lego blocks -- they link together in a specific, limited way that gives you the freedom to create great, complex edifices.

There is a natural social grammar, if you will, analogous to the natural syntax on which our vast diversity of languages is built. Children who are not autistic quickly acquire this social grammar as easily as they acquire language. It is intuitive, and it is also universal. Although politeness rituals and taboos vary across cultures, these can be described for us by an etiquette book or a human guide, and armed with this intellectual understanding we can readily associate with people of any culture and form friendships and even intimate attachments. We understand that relationships require reciprocity, recognition of the other's needs, boundaries, how much emotional availability they have for you, and whether or not they feel like spending time with you at this particular moment, among other kinds of limits. We get that demanding too much of other people is counterproductive.

The word normal has 3 meanings. It can mean corresponding to moral norms; it can mean average or typical; and it can mean "as we would desire things to be." Whether a person is average or typical in some way often just doesn't matter, or a person can be deviant in a good way, e.g. abnormally intelligent. Homosexuality is abnormal in the sense of being a minority condition, but whether it is abnormal in either the first or third sense is entirely dependent on circumstances. We can just decide that it's not immoral and that's the end of that, and after that the only reason I can think of offhand that it might conceivably be undesirable is if we are in danger of extinction, which we aren't. But BPD is inherently abnormal in the third sense. It just doesn't work.

Finally, there is a lesson here for all of us. Even if we don't merit the diagnosis, there may be a little bit of the maladaptive behavior in most of us. It's easy to slip into dependency, or demanding more of people than they can comfortably give, not giving enough in return, making a relationship more about ourselves than about each other. It's always good to think about that.

6 comments:

so sorry about your family emergency, and hope that things work out as best they can.

thanks for this post. the inclusion of homosexuality in early DSM's was obviously wrong: a person's inherent gayness is not harmful in itself, neither to oneself nor others. people can't help whom they love, and love is good. [fabulousness is, in my opinion, an excellent collateral benefit for a segment of the population.]

my interest here is pretty much personal -- although your recent post about AIDS denialism made me wonder if a few charismatic, high-functioning members of the BPD club might fuel the fires, drawing on lifelong skills. you hit the nail on the head with: "there is something close to delusional about them, it just drives you nuts trying to get them to have useful insight into their own behavior."

my husband and i are each blessed with a sister who [albeit not diagosed] fits the patterns of freaking out and acting out in crisis; wild swings between total devotion and total disdain; manipulation; victimhood; neediness; blaming; intentionally causing [at least emotional, sometimes worse] harm to others when crossed; and an inability to put themselves in another's shoes, to listen, to respond with empathy, to admit any error on their own parts. it's always all about them. they are always right.

with a co-worker, neighbor, acquaintance, it is relatively easy to draw some boundaries, and no big loss when they move on to other targets. a bit harder with close relatives -- particularly when something bad actually does happen to them.

one has been diagnosed with early dementia, has no current income and is unemployable, but strenuously objects to any restraints on her decisionmaking. the other has been diagnosed with breast cancer, probably at least stage 2. one expects a bailout nearly every day; the other figured her diagnosis was an occasion to beat the sibs over the head with made-up grievances extending back over a decade. we are doing a lot of thinking about how to be decent people in these circumstances.

Viagra pill is important confidence booster for men who are insecure about their sexual performance. The powerful combination of Viagra and mental thoughts is the fastest and most effective way to improve sex drive and get more pleasure out of sex than ever before. http://www.viagrathunder.com

Generic Viagra is used in the treatment of Erectile Dysfunction (impotence), but it is not a cure. Impotence can be caused by a number of factors, either physical or psychological. Viagra can help maintain an erection but it will not stimulate arousal.